A novel technique for tumor localization and targeted lymphatic mapping in early-stage lung cancer.

OBJECTIVE: To investigate safety and feasibility of navigational bronchoscopy (NB)-guided near-infrared (NIR) localization of small, ill-defined lung lesions and sentinel lymph nodes (SLN) for accurate staging in patients with non-small cell lung cancer (NSCLC). METHODS: Patients with known or suspected stage I NSCLC were enrolled in a prospective pilot trial for lesion localization and SLN mapping via NB-guided NIR marking. Successful localization, SLN detection rates, histopathologic status of SLN versus overall nodes, and concordance to initial clinical stage were measured. Ex vivo confirmation of NIR+ SLNs and adverse events were recorded. RESULTS: Twelve patients underwent NB-guided marking with indocyanine green of lung lesions ranging in size from 0.4 to 2.2 cm and located 0.1 to 3 cm from the pleural surface. An NIR+ "tattoo" was identified in all cases. Ten patients were diagnosed with NSCLC and 9 SLNs were identified in 8 of the 10 patients, resulting in an 80% SLN detection rate. SLN pathologic status was 100% sensitive and specific for overall nodal status with no false-negative results. Despite previous nodal sampling, one patient was found to have metastatic disease in the SLN alone, a 12.5% rate of disease upstaging with NIR SLN mapping. SLN were detectable for up to 3 hours, allowing time for obtaining a tissue diagnosis and surgical resection. There were no adverse events associated with NB-labeling or indocyanine green dye itself. CONCLUSIONS: NB-guided NIR lesion localization and SLN identification was safe and feasible. This minimally invasive image-guided technique may permit the accurate localization and nodal staging of early stage lung cancers.

Recent trends in surgical research of cancer treatment in the elderly, with a primary focus on lung cancer: Presentation at the 2015 annual meeting of SIOG.

Surgical research concentrating on cancer in the elderly has changed from small single institution outcome studies of carefully selected patients to larger studies that test specific aspects of surgical selection, treatment, and outcome. The purpose of this paper is to review major new trends in surgical geriatric oncology research within the last decade. Reviewing PubMed listings of the last 10years reveals several identifiable areas of particular concentration. Although we use specific studies primarily from lung cancer treatment, the generalizations can be seen across the spectrum of geriatric cancers. These trends include screening for disease that can be successfully treated, integration of operative and non-operative therapies that are changing the indications for surgery, the use of prehabilitation to allow more borderline frail patients to be treated surgically, the use of rehabilitation to facilitate rapid and complete recovery, prevention and treatment of common morbidities, with a special recent focus on delirium and cognitive impairment. New areas of surgical research include research on team building in the OR and ICU. Recent surgical research is becoming quantitative and multi-institutionally based. Overall surgical mortality has dropped over the past 25years in both academic and community hospitals. Prevention of morbidity and loss of functional status is a major focus of research. Funding for new Quality Assurance Projects for elderly patients has been awarded to the American College of Surgeons, and should provide multi-institutional quality outcome data within 5years.

Safety and feasibility of near-infrared image-guided lymphatic mapping of regional lymph nodes in esophageal cancer.

OBJECTIVE: To assess safety and feasibility of an intraoperative, minimally invasive near-infrared (NIR) image-guided approach to lymphatic mapping in patients with esophageal cancer. METHODS: Although local lymph nodes (LNs) are removed with the esophageal specimen, no techniques are available to identify the regional LNs (separate from the esophagus) during esophagectomy. We hypothesize that NIR imaging can identify regional LNs with the potential to improve staging and guide the extent of lymphadenectomy. Nine of the 10 patients enrolled had resectable esophageal adenocarcinoma and underwent NIR mapping following peritumoral submucosal injection of indocyanine green (ICG) alone or premixed in human serum albumin (ICG:HSA) before resection. NIR imaging was performed in situ and ex vivo. RESULTS: In 6 of the 10 patients, intraoperative NIR imaging demonstrated an NIR signal at all tumors and in 2 to 6 NIR(+) regional LNs. NIR(+) LNs were not identified in 4 patients: 1 patient with occult stage IV disease, for whom further imaging was not performed and thus was excluded from analysis, and 3 patients in whom ICG was used without HSA. Identification of local LNs on the esophagus was obscured by a peritumoral background. Importantly, the pathological status of NIR(+) regional LNs reflected overall regional nodal status. CONCLUSIONS: NIR lymphatic mapping is safe and feasible in patients with esophageal cancer and can identify regional LNs when ICG:HSA is used. Although more work is needed to improve background signals and local LN identification, intraoperative detection of regional NIR(+) LNs allows an in-depth histological analysis of LN basins not commonly scrutinized as part of the specimen and may improve the detection of occult nodal disease.

Thirty-Day Mortality After Lobectomy in Elderly Patients Eligible for Lung Cancer Screening.

BACKGROUND: Whether US surgeons have been able to replicate the low mortality rate of 1% after lobectomy experienced by patients treated in the National Lung Screening Trial is unknown. METHODS: To determine current operative 30-day mortality rates after lobectomy, we analyzed American College of Surgeons National Surgical Quality Improvement Program data files from 2005 to 2012. RESULTS: Of the 2,690 patients analyzed, 1,595 underwent open thoracotomy lobectomy and 1,095 underwent video-assisted thoracoscopic lobectomy. Sixty-three postoperative deaths occurred among the 2,690 patients (2.34% overall). The mortality rate for open lobectomy was 3.13% (50 cases) and that for video-assisted thoracoscopic lobectomy was 1.19% (13 cases [odds ratio 2.69, 95% confidence interval: 1.43 to 5.43, p < 0.05). Evaluation of mortality rates between surgical approaches (open versus video-assisted thoracoscopic) was performed by age group: group 1, aged 65 to 69 years (odds ratio 2.72, 95% confidence interval: 1 to 9.4, p < 0.05); group 2, aged 70 to 74 years (odds ratio 4.41, 95% confidence interval: 1.28 to 23.4, p < 0.05); and group 3, aged 75 to 80 years (no difference was found in group 3, p = 0.45). CONCLUSIONS: Among the hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program, operative mortality rates after lobectomy are comparable to the operative mortality rates in the National Lung Screening Trial.

Surgical resection of lung cancer in the elderly.

Assessment for thoracic surgery in elderly patients should be based on physiologic rather than chronologic age. Thoracic surgery has been shown to be safe in selected elderly patients, and age should not be a contraindication to a therapy that offers the best chance of cure for patients with early-stage cancer. A targeted preoperative assessment can help individualize the risk of morbidity and mortality for each patient, and thus provide both surgeon and patient with the information needed for operative decision making. Operative interventions in the elderly require coordinated attention to the specific requirements of the aged. Specialized multidisciplinary care provided by primary care physicians, geriatric specialists, cardiologists, oncologists, surgeons, anesthetists, nurses, physical therapists, and nutrition specialists optimizes care for the elderly patient undergoing thoracic surgery. Careful selection of patients for surgery has contributed to the improvement in operative mortality over time, and refinements in preoperative testing should continue this trend in the future. The goal is to provide surgery to the maximum number of patients at the minimal cost of mortality and loss of independence.